At LAC+USC Medical Center in Los Angeles, Calif., an acuity-based approach to staffing led to real-time assignments that efficiently delegated care to patients. The center’s direct care nurses say it resulted in evenly distributed work that reduced nurse burnout and also created new opportunities.
Supervising Staff Nurse Maurice Kibisu, RN, spoke with AACN Clinical Practice Specialist Sarah Delgado about the system and strategies he learned for more effective staffing. Do you have a successful staffing solution that works in your unit or facility? We want to hear from you. Submit your solution.
Sarah Delgado:
Can you tell us about your experience as a direct care nurse and a charge nurse, and what it's like to use an acuity-based staffing tool that works in conjunction with the electronic health record?
Maurice Kibisu:
I'll start with my experience as a direct care nurse. I noticed immediately when we started using the acuity-based tool that the assignments were divided equally and evenly. I came to realize it's because the solution is based on patient acuity, and it’s in real time. So, it's easy for the charge nurse to assign the patients equally in terms of workload. As a direct care nurse, I noticed the assignments were evenly distributed and no one was getting burned out.
Another advantage is that direct care nurses have open opportunities. You just have to enroll in the system and then you get notified by text messages if there are open opportunities to work. Before this, it used to be that nurses had to sit home and wait for the staffing unit to call you and ask you, "Hey, do you want to work?" This creates an opportunity for people who are not working to get in quickly and start working and saves a lot of time. Another advantage for a direct care nurse was that I was able to get time with the patient, as opposed to before where the assignments had to be changed in the middle of the shift, because the workload was heavier for the other nurses or the charge nurses needed time. With the acuity-based staffing tool, the charge nurse spends little time making assignments.
Now, as a charge nurse, we have the continuity of care option, so it's easy for me to make assignments. It's easy to see patients who are coming in, you can see their acuity, and it makes it easier for you to assign the patients to different nurses. In cardiac care, we have a lot of different machines that we use like ECMO or a balloon pump, but not all the nurses are trained in those machines. This tool tells you which nurses are skilled in that machine. It saves time as opposed to before when I used to call and find out. As a charge nurse, that really helped me in assigning the nurses with the patients’ acuity levels.
Delgado:
That's really interesting, Maurice, and I appreciate how you described the tool. It not only tells you the acuity of the patient, but it also tells you the skills of the nurse, so you can create that alignment. Can you describe the continuity of care feature a little bit more?
Kibisu:
The continuity of care tool comes hand-in-hand with the drag-and-drop tool. Most of the units here at LAC+USC have a top rotation and a bottom rotation. For example, we have the top rotation that would work Monday and Tuesday, and the bottom rotation works Wednesday and Thursday. Most nurses usually create a very good rapport with the patient that they're taking care of. So, you don't want to disrupt that rapport the following day. The continuity of care tool helps because it uses the same named of the nurses that were there the day before and assigns them the same patients that they had. This saves a lot of time that would've been spent trying to go the traditional way of creating assignments all over again.
Of course, we also look at the patient’s current acuity. If, for example, a patient got really sick overnight, the acuity level is going up. We can modify the assignment if a different nurse is a better fit to provide care.
Delgado:
I can see a value in that. What was the process for staffing before this tool came into play in your environment?
Kibisu:
Most of the staffing was done by the hospital staffing department. Some of the staff members in that department, however, don't have experience working on the floor or in the units. That made it complicated, because they're the ones who were in charge of staffing. They were looking at the numbers of nurses, but they're not looking at the qualifications of the nurses.
For example, I worked in the coronary care unit and sometimes the medical ICU would get an admission, a patient on ECMO. The staffing department would start calling the units asking, "Hey, we need somebody that is trained in ECMO; who do you have?" Then the charge nurse would start calling the nurses if they're at home or try to call them if they're in any unit. That's how staffing used to be. It was a lot of work and a lot of communication and not very much clarity.
Delgado:
Can you tell us about the transition to the new tool that you use in the electronic health record and what changed as a result? For instance, were there changes in documentation that were challenging or features that helped with that transition?
Kibisu:
The electronic health record program connected seamlessly with the staffing tool, so there were some changes in documentation as opposed to an increase in documentation. It was quality, streamlined and timely. There was the usual fear of change in some nurses; it's always there. The other issue that we had was an organizational issue. We had to adjust the ratios and the floor to make sure that we had enough people to work on the floor so we could take the nurses to classes to train on the new tool.
Delgado:
I think that's really an important consideration, Maurice. There was training that the nurses had to do. Was it an increase, do you think, in documentation or workload to switch to this system? Or was it just changing the process?
Kibisu:
There was no increase in workload; they just had to learn the new solution. As soon as the nurses understood what it was for and how to go about navigating it, life became much easier.
Delgado:
So there's the tool that helps the charge nurse make assignments that are equitable. Then there's also the scheduling piece that allows for this flexibility, where you can streamline the process for changing shifts.
Kibisu:
Yes. The scheduling process saves a lot of time for the supervisor and for the nurses. Supervisors will fill in the weekends, and nurses will input their own schedule on weekdays. This self-scheduling process has created some independence and reduced the number of sick calls.
Delgado:
For someone who was looking at transitioning to this kind of technology, what advice would you have for them?
Kibisu:
First of all, I would just advise them to invest in acuity-based software. It provides clarity and it provides a seamless process in staffing. Going back to acuity, this system releases so much work from everyone in general. From the charge nurse to the front-line staff, you save a lot of money and time. The hospital is going to save a lot of money. The patients are going to benefit because they're getting much-deserved time with the nurses at the bedside.
As a charge nurse, sometimes I had to call the nurses on the floor to remind them, "Hey, you need to do your acuity," and then the nurse would go in and start doing the acuity. Because they're in a rush, the acuity was never close to accurate. So, at the beginning of the shift, we are using that acuity to divide the assignment. The problem was mounting because the nurses who did the acuity did not do it the right way. The best thing about this acuity, this software, is that it's connected to documentation. It's real time. The acuity that you see is pulled from the documentation. Therefore, most of the time you're getting very, very good acuity, close to the accurate acuity of the patient. And this is a huge help to the organization, to the nurses and to the patients.
Delgado:
You talked about the automated scheduling system, and I wondered if you had any advice for a unit that was entertaining or implementing that change in their process. If they were looking at using the automated scheduling or the tool that notifies people about open shifts and automates schedule change requests, what advice would you give them?
Kibisu:
I would advise them to invest in an acuity-based staffing tool, because it's almost like it is doing everything for you. Nurses just have to know how to log into the solution and input data. The utilities may include self-scheduling, swap shifts, scheduling time off and opt-in on shift opportunities. Smart assignments take competencies into consideration and custom workload calculation is based on clinical condition. All these features help create balanced assignments and prevent staff burnout, no under or overstaffing, and better staff satisfaction and retention.
Delgado:
In turn, that allows the charge nurse to support staff in other ways because they're not spending all their time on the assignments.
Kibisu:
Absolutely. It's amazing. I've seen a lot of changes in the pilot units.